NOTES TO AGENTS:
Agents must provide all requested information then either fax or mail this form directly to the address listed below.
Pre-printed limits are the minimum required; if higher limits are provided by the policy, enter the higher limit amount
and strike-through or cross-out the pre-printed limit.
To avoid work suspension, an updated insurance form must reach the address listed below one business day
prior to the expiration date. Insurance must be in force in order to perform any work.
Binder numbers are not acceptable for policy numbers.
The certificate of insurance, once on file with the department, is adequate for subsequent department contracts
provided adequate coverage is still in effect. Do not refer to specific projects/contracts on this form.
List the contractor’s legal company name, including the DBA (doing business as) name as the insured. If a staff
leasing service is providing insurance to the contractor/client company, list the staff leasing service as the insured
and show the contractor/client company in parenthesis.
The TxDOT certificate of insurance form is the only acceptable proof of insurance for department contracts.
List the contractor’s legal company name, including the DBA (doing business as) name as the insured or list both the
contractor and staff leasing service as insured when a staff leasing service is providing insurance.
Over-stamping and/or over-typing entries on the certificate of insurance are not acceptable if such entries change the
provisions of the certificate in any manner.
This form may be reproduced.
DO NOT COMPLETE THIS FORM UNLESS THE WORKERS’ COMPENSATION POLICY IS ENDORSED WITH A
WAIVER OF SUBROGATION IN FAVOR OF TXDOT.
The SIGNATURE of the agent is required.
CERTIFICATE OF INSURANCE REQUIREMENTS:
WORKERS’ COMPENSATION INSURANCE:
The contractor is required to have Workers’ Compensation Insurance if the contractor has any employees including
The word STATUTORY, under limits of liability, means that the insurer would pay benefits allowed under the Texas
Workers’ Compensation Law.
GROUP HEALTH or ACCIDENT INSURANCE is not an acceptable substitute for Workers’ Compensation.
COMMERCIAL GENERAL LIABILITY INSURANCE:
If coverages are specified separately, they must be at least these amounts:
Bodily Injury $500,000 each occurrence
$100,000 each occurrence
Property Damage $100,000 for aggregate
MANUFACTURERS’ or CONTRACTOR LIABILITY INSURANCE is not an acceptable substitute for Comprehensive
General Liability Insurance or Commercial General Liability Insurance.
BUSINESS AUTOMOBILE POLICY:
PRIVATE AUTOMOBILE LIABILITY INSURANCE is not an acceptable substitute for a Business Automobile Policy.
MAIL ALL CERTIFICATES TO:
Texas Department of Transportation
CST Contract Processing Unit (RA/200 1st Fl.)
125 E. 11th Street
Austin, TX 78701-2483
512/416-2540 (Voice), 512/416-2536 (Fax)
Williams, McClure & Parmelee is dedicated to high quality legal representation of businesses and insurance companies in a variety of matters. We are experienced Fort Worth, Texas construction law defense lawyers in Tarrant County who know Texas courts and Texas law. For more information, please contact the law firm at 817-335-8800. The firm’s office location is 5601 Bridge Street, Suite 300, Fort Worth, Texas 76112.